Gastroesophageal reflux (GORD) is the movement of gastric contents into the oesophagus which can cause a range of symptoms from hiccups and burping to pain and physical discomfort. It can cause tissue damage leading to complications such as ulcers. “The symptoms most commonly experienced are heartburn and acid regurgitation,” said Dr Greg Renzulli.
OTC medication options
Advantages and disadvantages of OTC treatment options
Proton pump inhibitors (PPIs) reduce the amount of acid made by the stomach. They do this by irreversibly blocking the actions of an enzyme responsible for acid production, H+/K+ ATPase, located in the parietal cells in the stomach wall.
Over the counter (OTC) PPIs are widely acknowledged to be the most effective treatment for symptom relief of gastro-oesophageal reflux. “There is lots of data to support this. Compared to other treatment options, OTC PPIs have demonstrated benefits to symptom resolution and quality of life, as well as the practical advantage of one-daily dosing.
ROLE OF THE PHARMACIST IN THE RECOMMENDATION AND USE OF OTC PPIs
1. Confirm the diagnosis: Extensive OTC knowledge and familiarity with patients make pharmacists the ideal healthcare professional to select appropriate medication.
2. Refer patients with ‘alarm symptoms’ to a doctor or specialist.
3. Ensure proper use of OTC PPIs:
- Unlike antacids, communicate that PPIs should not be taken symptomatically
- Should be taken once daily at the same time every day
- OTC PPI usage should be limited to 14-28 days without consulting a doctor
- If symptoms recur:
- Immediately after a course of OTC PPIs, the patient should consult with their doctor
- After 4 months, a subsequent course of OTC PPIs can be initiated
4. Set expectations of treatment with OTC PPIs:
- A third of patients will experience relief of heartburn symptoms within a few days of starting treatment
- 55-80% of patients will experience first resolution/relief of heartburn symptoms within the first week of treatment
5. Advise lifestyle changes including avoiding known triggers, which can increase the likelihood of treatment success.
QUESTIONS TO IDENTIFY APPROPRIATE CANDIDATES FOR OTC PPI THERAPY
“It’s important that you ask the right questions,” said Dr Renzulli. “Often episodic heartburn cases are in fact frequent heartburn cases.”
WHEN TO RECOMMEND OTC PPIS
Concerns about recommending OTC PPIs and other therapies
- The possibility of misdiagnoses
- Under-treatment of patients with severe GORD who require supervised medical care rather than OTC therapy
The ‘ideal’ patient for an OTC PPI recommendation
- Those presenting with typical symptoms of heartburn and/or acid regurgitation as their main or predominant complaint
- Patient experiences frequent heartburn rather than infrequent heartburn
SELFCARE ALGORITHM FOR HEARTBURN MANAGEMENT
“Selfcare algorithms are useful but they need to be managed by someone other than the patient,” said Dr Renzulli. “Obviously the patient needs to be involved, but we all know they can be irresponsible. This is where pharmacists and pharmacist assistants are important. Although they’re called ‘self-care’ algorithms, it’s beneficial to have someone with knowledge overseeing it and advising patients. Especially if patients keep coming back too often.
ATYPICAL SYMPTOMS OR ALARM FEATURES THAT REQUIRE EVALUATION BY A DOCTOR
- Gastrointestinal bleeding
- Iron deficiency anaemia
- Involuntary weight loss
- Difficult/painful swallowing (dysphagia)
- Chest pain
- Choking attacks, especially at night
- Recurrent cough/hoarseness
- Epigastric mass/lymphadenopathy
- Family history of oesophageal adenocarcinoma
- New onset of symptoms > 50 years of age